In a Chemical Factory, A precious material spill into Reactor.
After a short research, night before at the control room there were a lot of alerts so the operator disconnected the alert.
Does that operator should be punished or not?
My opinion is that the Operator shouldn’t be punished:
- The operator for a reactor apparently works there for a lot of time cause he was at night shift and operated the reactor.
- If the operator shut down the alert of the leak, it means that he learned it from other operators.
- According to this behavior we can learn a lot about the culture and norms of that company.
- After about 3.5 times of repeating a task, then a person would learn about 80% of an operation.
- “Best Practice” – although it is talked a lot, the true meaning is that there are things that will be learned only while experiencing practically.
- When researching a case or abnormal event, while failures are researched and investigated, also successes should be researched and learned.
3 new things that I leaned at this lesson are: